Journal of Sex &Marital Therapy

ISSN: 0092-623X (Print) 1521-0715 (Online) Journal homepage: https://www.tandfonline.com/loi/usmt20

How Does Premature Ejaculation Impact a Man’s

Life?

T. SYMONDS , D. ROBLIN , K. HART & S. ALTHOF

To cite this article: T. SYMONDS , D. ROBLIN , K. HART & S. ALTHOF (2003) How Does
Premature Ejaculation Impact a Man’s Life?, Journal of Sex &Marital Therapy, 29:5, 361-370, DOI:
10.1080/00926230390224738

To link to this article: https://doi.org/10.1080/00926230390224738

Published online: 19 Jan 2011.

Submit your article to this journal

Article views: 7148

View related articles

Citing articles: 26 View citing articles

Full Terms & Conditions of access and use can be found at

https://www.tandfonline.com/action/journalInformation?journalCode=usmt20
Journal of Sex & Marital Therapy, 29:361–370, 2003
Copyright © 2003 Brunner-Routledge
ISSN: 0092-632X print / 1521-0715 online
DOI: 10.1080/00926230390224738

How Does Premature Ejaculation Impact a

Man’s Life?
T. SYMONDS, D. ROBLIN, AND K. HART
Pfizer Global Research & Development, Sandwich, Kent, United Kingdom
S. ALTHOF
Center for Marital and Sexual Health, Beachwood, Ohio, USA

No systematic study has examined the psychological impact of pre-

mature ejaculation (PE) on the man and his partner. This study
explores this vital issue by reporting on interviews of 28 men with
self-diagnosed PE. From a qualitative perspective, these interviews
assess whether these men had concerns about their PE and, if so,
what they were. These men focused on two major themes: impact
on self-confidence and future/current relationships. This suggests
that PE has a similar qualitative impact on the individual as erec-
tile dysfunction. Further investigation will need to determine how
prevalent these concerns are in the PE population and also to de-
lineate the impact on the men’s partners.

Premature ejaculation (PE), also referred to as rapid ejaculation, is a preva-

lent condition with between 22 and 38% of the adult male population suffer-
ing from this disorder (Laumann, Paik, & Rosen, 1999; Spector & Carey,
1990). Some specialists believe that PE is the most common male sexual
disorder, affecting perhaps as many as 75% of men at some point in their
lives (McMahon, 1998). Patients with sexual dysfunction are reluctant to raise
the subject of ejaculatory dysfunction with their physician because they are
embarrassed and uncertain if efficacious treatments exist to remedy their
problem. Clinicians fail to ask about sexual matters because they are more
concerned with health conditions with associated mortality and morbidity
risks, are under intense time pressure, and may be uncomfortable asking
patients about their sexual lives. Perhaps these phenomena account for Aus-
tralian and Canadian doctors reporting that they found a rate of sexual dys-
function of only 0.2–5.4% in their patients (Fisher, 1986; Littman & Arnot,

Address correspondence to Tara Symonds, Outcomes Research, Pfizer Global Research

& Development, Sandwich Laboratories, Pfizer Ltd., Sandwich, Kent, CT13 9NJ, United
Kingdom. E-mail: tara_symonds@sandwich. pfizer.com

361
362 T. Symonds et al.

1987). Moreover, in the case of PE, this is coupled with the lack of recogni-
tion of PE as causing patients and partners significant distress and the limited
choice and lack of awareness of the available therapeutic options. It could
also be that some men do not care about their ejaculatory dysfunction or,
perhaps, they are either selfish lovers or are unconcerned with how long
they last. Finally, they may deny, minimize, or not recognize PE as a signifi-
cant problem, and it is only when their partner complains that men then
seek treatment.
Both the Diagnostic and Statistical Manual of Mental Disorders (DSM-
IV; American Psychiatric Association, 1994) and the International Statistical
Classification of Diseases and Related Health Problems (ICD-10; World Health
Organization, 1992–1994) provide definitions of PE:

• DSM-IV criteria: “PE is persistent or recurrent ejaculation with minimal

sexual stimulation before, upon, or shortly after penetration and before the
person wishes it and is associated with marked distress or interpersonal
difficulty” (APA, 1994).
• ICD-10 definition: “There is an inability to delay ejaculation sufficiently to
enjoy lovemaking, manifest as either of the following: (1) occurrence of
ejaculation before or very soon after the beginning of intercourse (if a time
limit is required: before or within 15 seconds of the beginning of inter-
course); (2) ejaculation occurs in the absence of sufficient erection to make
intercourse possible. The problem is not the result of prolonged abstinence
from sexual activity” (WHO, 1992–1994).

The DSM-IV criteria are nonspecific, relying heavily on the clinician’s

judgment as to what constitutes “before, upon, or shortly after penetration.”
Similarly, it calls for judgment regarding lack of control of ejaculation and
interpersonal difficulties. The ICD-10 definition provides more of a focus on
latency and, indeed, defines a latency time postintromission of within 15 s of
the beginning of intercourse. DSM-IV also calls for three additional specifiers
when diagnosing rapid ejaculation: lifelong versus acquired, generalized versus
situational, and that due to psychological factors versus that due to com-
bined factors.
Clinicians use the distinction between primary (lifelong) and secondary
(acquired) to determine the focus of treatment. If a man has never achieved
control, clinicians presume that this is a developmental problem because an
issue has never been sufficiently resolved. Secondary problems suggest that
something relatively recent has happened, and clinicians tend to focus on
the recent past. Terms such as psychogenic and organic, although suitable as
descriptors for erectile dysfunction (ED), remain hypothetical for PE (Rowland
& Slob, 1997).
Limited attempts to provide a consensus and more objective criteria for
the diagnosis of PE have not succeeded. Despite this, most men presenting
with PE readily recognize their problem, and there is no lack of self-diagno-
 Impact of Premature Ejaculation 363

sis. There is no clear definition of the intravaginal ejaculatory latency time

(IELT) that qualifies for the diagnosis of PE. Waldinger, Hengeveld,
Zwinderman, and Olivier (1998) argue that the standard be set at an IELT of
less than 1 min. Others would recommend that PE be defined to occur prior
to or within 1 to 2 min following vaginal intromission. Men with latencies
above 3 min are thought to overlap with sexually functioning individuals
who do not view themselves as having a problem. Men with PE also report
little or no control over ejaculation, whereas sexually functional men do
perceive a relatively high degree of control. Unfortunately, there is no well-
controlled study of ejaculatory latency in normal men over the life span. We
do not know if IELT stays the same, increases, or decreases with age.

TREATMENT

The cause of PE has been considered to be more psychological than

physiological. Because of this assumption, sex therapy was considered
the treatment of choice with behavioral and/or cognitive approaches prov-
ing to be the most successful. These approaches include the stop-start
technique developed in 1956 by Semans and later adopted by Masters &
Johnson (1970), as well as other psychotherapeutic approaches that have
become the gold standard for treatment of PE (Seftel & Althof, 1997).
Many of these techniques require some degree of partner cooperation
and have been associated with short-term success rates of 43–65%, de-
pending on the population studied, motivation, and therapist (St. Lawrence
& Madakasira, 1992). However, most patients do not maintain benefits,
and relapse is common (Bancroft & Coles, 1976; DeAmicus, Goldberg,
Lopicollo, Friedman, & Davies, 1985).
No pharmacological agents are licensed for use in PE. However, certain
antidepressants (monoamine oxidase inhibitors, tricyclic antidepressants, selec-
tive serotonin reuptake inhibitors [SSRIs]) and other drug classes (topical anaes-
thesia, neuroleptics, α-blockers, β-blockers, anxiolytics, smooth muscle relax-
ants), as well as oral PDE5 inhibitor agents (e.g., sildenafil), have been used
off-label and in clinical studies (Chen, Greenstein, Mabjeesh, & Matzkin, 2001;
Roblin, 2000). Double-blind, placebo-controlled studies with clomipramine and
the major SSRIs, using strict dosages in carefully selected populations, have
repeatedly demonstrated that these agents are efficacious in delaying ejacula-
tion. However, when subjects discontinue the medication, improvements are
lost, and ejaculation latencies tend to return to baseline.

THE PSYCHOLOGICAL IMPACT OF PE

The effect of this condition on men is poorly understood; however, it can

cause significant distress. Indeed, the DSM-IV (APA, 1994) definition necessi-
364 T. Symonds et al.

tates “distress” for PE to be considered a problem. Within the DSM-IV defini-

tion, reference is also made to “interpersonal difficulty,” perhaps referring to
the embarrassing nature of the dysfunction resulting in men moving away
from beginning or establishing new relationships, or even when PE may
have a negative impact on men and their partners in a stable relationship
(Rust, Golombok, & Collier, 1988). It has also been shown that dissatisfac-
tion with sex life is highest in men with PE, compared with those who have
erectile difficulties (Moore & Goldstein, 1980).
Anecdotal reports suggest that PE impacts a man’s quality of life (QoL);
however, there is little specific detail of what particular aspects of his QoL
are affected. PE has been associated with increased anxiety, as assessed in a
large-scale population survey (Dunn, Croft, & Hackett, 1999). To date, there
has been little direct interviewing of patients about what the issues are for
men who ejaculate prematurely. We therefore conducted 28 interviews with
PE sufferers to specifically probe how this condition has affected their life
and to inquire about what treatment options, if any, men were aware of and
had tried. Barriers to treatment seeking were also examined.

METHOD

As part of a program to understand the condition of PE, we conducted a

series of 28 qualitative individual in-person interviews with self-reported PE
sufferers in three states, New Jersey, California, and Illinois, during August
1999. We recruited PE sufferers via newspaper advertisements and then
screened them via telephone prior to individual interviews. Study partici-
pants were required to have experienced PE (by their own definition) for at
least 2 years. They were also required to be between the ages of 25 and 70
and to be free from alcohol or drug dependency (all self-reported).
We designed the sample to include each of the following, although no
specific quotas were set:

• A range of ages;
• A range of self-reported severity (mild/moderate/severe PE) and a range
of treatments pursued;
• A range of relationship status at time of interview (with/without a “steady”
sexual partner);
• Individuals with and without a diagnosis of PE from a sex therapist or
primary care physician.

We did not stipulate a requirement for a specific time to ejaculation for study
participation; we only required that the man feel that he ejaculated prema-
turely. Through the course of the interview, each participant mentioned la-
tency times. As might be expected, there was a wide range of times men-
tioned, from prior to intromission to 10 min. However, the majority of men
 Impact of Premature Ejaculation 365

sampled (79%) reported ejaculating between “prior or on penetration” to “2

minutes” post penetration. Table 1 summarizes the sample characteristics.
Interviews were carried out by two male researchers, lasted 30–45 min,
and were tape-recorded and subsequently transcribed to enable analysis.
The interviews followed a semistructured discussion format, with open-ended
questions designed to explore the sufferer’s experience and views on PE.
The section of the interview that is reported here questioned respondents on
the impact, if any, that PE has had on their self-image (“what impact, if any,
has the condition had on the way you see yourself?”), their sex life (“what
impact, if any, has the condition had on your sex life?”), general relationship
with partner (“in what way, if any, has the condition had an impact on your
relationship with a partner?”), and their everyday life (“what impact, if any,
has your condition had on your everyday life?”). Interviewees were also
asked about their experience of treatment options.
We analyzed the transcripts of the interviews to ascertain recurring themes
and concepts. Since these themes were similar regardless of severity of the
condition, time to ejaculation (inclusive of the two men with latency times
between 5 and 10 min), and previous diagnosis or not, we present the re-
sults as one group.

RESULTS

Impact on a Man’s Lfe

The overriding concern for men with PE was the erosion of their sexual self-
confidence. To a lesser extent, they also were concerned with the impact of

TABLE 1. Sample Characteristics of the 28 Men Sampled

Age 26–35: 28%
35–50: 36%
51–70: 36%
Mean age (n = 26): 45.54 (SD = 11.99)
Severity
(Self-reported) Severe: 28%
Moderate: 68%
Mild: 4%
Lifelong or acquired condition
Lifelong: 46%
Acquired: 54%
Sought treatment from a physician
/other healthcare professional Yes: 39%
No: 61%
Current relationship status
“Steady”: 82%
Not with “steady”: 18%
366 T. Symonds et al.

the sexual dysfunction on their relationship, anxiety around performing ad-

equately, embarrassment about having the condition, and feelings of depres-
sion.

SELF-ESTEEM
Three quarters (68%) of interviewees mentioned that “confidence” generally
or in a sexual encounter was affected by their PE. PE has connotations that
“longer equals better,” which may be the main influencing factor for impact
on confidence. The following are examples of how men spoke about the
effect on their confidence:
“It’s deflated my confidence, a lot”; “Well yeah. It does affect the way you see
yourself because . . . you kind of get down on yourself sometimes”; “I think
you lose a little self-esteem having a problem”; “Makes me feel inferior to
what I suspect is the average.”
There were a number of occasions when reduced confidence was spe-
cifically attributed to loss of confidence as a sexual partner:
“Lower self-esteem. I’m not going out with many girls anymore. I’m just
afraid”; “I would say not sure of myself in a relationship. You feel like you’re
not capable, like you’re half the man you should be. It drives you to the
point where you stress yourself out”; “Yeah. Because I feel like I’m not, the
best way to put it, living up to my manhood.”

RELATIONSHIP
Relationship issues were the second most widely mentioned issue re-
ported by the sample (50%). Specifically, men focused on their reluc-
tance to establish new relationships (other than for reasons of lack of
self-confidence, as explained earlier), and for men in existing relation-
ships, on their distress regarding not satisfying their partner. It is perhaps
this area of initiating relationships that is of most concern for the PE
sufferer, because he is reluctant to enter into a sexual encounter for fear
of disappointing his partner or for fear of ridicule because he cannot
perform adequately: “A lot of times I would avoid getting too involved
with anybody because of the simple fact that I just really thought it was
like a lost deal. So I didn’t want to get too serious because there was too
much pain involved in it”; “Yeah. Sometimes you try not to have relation-
ships, kind of because you want to avoid that because it’s like a depress-
ing thing”; “When you’re looking for a partner you tend to think about it
more. At least I tend to think about it more. Or in the initial stages when
you are dating, you’re thinking about it to that point.”
There is also the issue of how PE affects the man’s life once he is in a
relationship. One interviewee was particularly concerned about his inability
to satisfy his wife. Another interviewee, because of feelings of inferiority and
insecurity, would argue more with his wife: “It does bother me that some-
times I can’t make my spouse achieve an orgasm”; “We get into a lot of
 Impact of Premature Ejaculation 367

arguments . . . If she’s going out sometimes I think that she’s cheating. Things
like that.”
The overriding problem for the PE interviewee was initiating a new
relationship. Those already with a partner had found understanding partners
and/or had found ways around the problem. Starting and maintaining a
relationship may arguably be a larger issue for PE patients than for ED suffer-
ers because a large proportion of PE sufferers are in the younger age range
and therefore probably more likely to still be dating.

ANXIETY
Anxiety often is mentioned as either being a reason for PE or a consequence
of PE, but, more often, it is a combination of the two. It is perhaps surprising
then that only 36% of interviewees specifically mentioned feeling anxiety
related to their PE (either causing it or because of it): “Anxious, all the time
anxious (about having sex)”; “A little bit (anxious). I used to all the time. I
used to all the time (be anxious)”; “all that contributes towards kind of an
inner turmoil that causes anxiety.”

EMBARRASSMENT AND DEPRESSION

Less widely mentioned effects of PE were embarrassment about the condi-
tion and depression. However, this may be an underreporting, because the
interviewer never directly asked if PE had resulted in any feelings of embar-
rassment or depression. It could be that PE is similar to the ED research,
where there is a strong correlation (not cause and effect) between ED and
depression. We now know that men with ED suffer from depression signifi-
cantly more often than men without ED (Seidman, Roose, Menza, Shabsigh,
& Rosen, 2001; Shabsigh et al. 1998): “It’s just I’m dead. It’s very embarrass-
ing and I just don’t feel good after that”, “It was me I was kind of ashamed of
it, embarrassed. I didn’t feel like I was satisfying my partner or satisfying
myself. The image”; “I wouldn’t say it causes anxiety. It’s a little depressing
knowing you’re not fulfilling your wife, that’s the thing about it”; “Well the
more you think about things you have no control over the more depressing
it is, and depression is not a good thing to be carrying around with you all
the time.”

TREATMENT AWARENESS
Eighty-nine percent of interviewees have tried some form of treatment for
their PE, regardless of whether or not they have consulted a health care
professional. As Table 2 highlights, the most commonly cited approaches
tried were more behavioral/psychological approaches. A number of men
(21%) had also tried a variety of herbal remedies and/or creams and lotions.
It is interesting to note that, of those men who had sought treatment from a
physician, 38% had tried some form of pharmaceutical drug even though no
drugs are licensed for use in this condition.
368 T. Symonds et al.

The primary reason cited by men for not consulting a physician about
their PE was the embarrassment of talking about this topic (67%). But nearly
half the men (47%) also believe that there is no treatment and therefore have
never considered consulting a physician.

CONCLUSION

Two major themes emerged from the qualitative interviews of men suffering
from PE. They were the men’s sense of PE causing lower self-esteem and
their concern with the impact of the dysfunction on forming a relationship.
Other issues were mentioned but to a lesser extent. The open nature of the
interview may have led to an underreporting of some issues. Further prob-
ing of impact on emotional health may have produced more discussion of
these issues. But, in general, the results from these interviews are in keeping
with the assumed impact implicit within the DSM-IV definition of PE and
also in the report by Rust, Golombok, and Collier (1988).
In those clinical trials where off-label use of antidepressants have been
used, the primary endpoint for efficacy is IELT. The DSM-IV definition com-
bines the idea of latency and control as important aspects of the condition,
and it has been recommended that these two be dual criteria of assessment
(Grenier & Byers, 1995). But from these interviews, there is also a clear case
to consider assessing additional concepts around QoL (avoidance of rela-
tionships, impact on current relationship, psychological well-being, depres-
sion, self-esteem, sexual self-confidence, sense of masculinity, and impact
on the partner). Future studies, which aim to assess the impact of therapy,
should therefore focus on not only objective measures such as latency and,
to a certain extent, control but also the impact on the man’s relationship and
self-esteem.
It is interesting to note that there was no direct correlation between the
severity and the time to ejaculation reported by the respondents. For ex-
ample, three (50%) of those who report ejaculation times of prior to or on
penetration classified themselves as moderate, and three (50%) classified
themselves as severe. Furthermore, men who self-diagnosed themselves as
severe or moderate also reported similar concerns about their PE. It would
not be possible to state from looking at a particular transcript whether the

TABLE 2. Treatment Options Tried by All Men Regardless of Whether or Not They Had
Previously Consulted a Health Care Professional for Treatment
Treatment option % of all men
Stop-start-squeeze technique 54%
Distraction/focus technique 36%
Creams/lotions/thicker condoms 21%
Masturbation prior to intercourse 21%
Herbal treatment 21%
 Impact of Premature Ejaculation 369

man considered himself a severe or moderate PE sufferer. Similarly, severity

did not predict the men who did and did not seek treatment. Some clinicians
believe that PE is not as distressing as ED, which is the reason why many
men choose not to seek treatment. However, the results of this study would
argue that it is more a function of the embarrassing nature of the condition
and the belief that there are no efficacious treatments. Although, it could be
that some men only seek treatment because of partner need rather than their
own concern; this was not explored in the interviewees and would be some-
thing to be considered in a future similar study.
The opportunity sampling method that we used allowed men who felt
comfortable talking about their condition to volunteer for the interviews;
therefore, these participants are more likely to be comfortable speaking openly
and candidly about their experience of having PE. However, our sample
may not be representative of the population of PE sufferers and therefore
might be biased. For example, we do not know if the present participants
are more or less distressed about their PE and, therefore, the issues they
report may be an over or under report of the PE population as a whole.
Future studies might consider using more specific sampling techniques to
ensure representativeness.
Twenty-eight men may be a low figure for such a qualitative study;
however, our aim was to begin to understand the concerns and issues of
men with PE rather than relying on anecdotal reports. A future study
might probe further the issues around self-esteem and relationships. These
interviews may specifically look at anxiety, depression, and embarrass-
ment to ensure these are, or are not, truly concerns. Additionally, inter-
views with partners would elucidate the salient issues from their indi-
vidual perspective.
Overall, this study has provided a first insight into how men with PE feel
and talk about their condition. The main issues were self-esteem and rela-
tionship. These issues should be investigated further in any future studies
looking at impact of PE on men’s lives. It may also be worthwhile to inter-
view partners to determine what the impact is to them also.

REFERENCES

American Psychiatric Association. (1994). Diagnostic and statistical manual of men-

tal disorders (4th ed.). Washington, D.C.: Author.
Bancroft, J., & Coles, L. (1976). Three years experience in a sexual problems clinic.
British Medical Journal, 1 (Suppl. 4), 1575.
Chen, J., Greenstein, A., Mabjeesh, N. J., & Matzkin, H. (2001). Role of sildenafil in
the treatment of premature ejaculation. International Journal of Impotence Re-
search, 13, S48.
DeAmicus, L. A., Goldberg, D. C., Lopicollo, J., Friedman, J., & Davies, L. (1985).
Clinical follow up of couples treated for sexual dysfunction. Archives of Sexual
Behavior, 14, 467.
370 T. Symonds et al.

Dunn, K. M., Croft, P. R., & Hackett, G. I. (1999). Association of sexual problems
with social, psychological, and physical problems in men and women: A cross
sectional population survey. Journal of Epidemiology and Community Health,
53, 144–148.
Fisher, E. (1986). Common sexual problems in general practice. Australian Family
Physician, 15, 43–47.
Grenier, G., & Byers, E. S. (1995). Rapid ejaculation: A review of conceptual etiologi-
cal, and treatment issues. Archives of Sexual Behaviour, 24, 447–472.
Laumann, E. O., Paik, A,. & Rosen, R. C. (1999). Sexual dysfunction in the United
States: Prevalence and predictors. Journal of the American Medical Association,
281, 537–544.
Littman, S. K., & Arnot, P. (1987). Sexual dysfunction. A survey of Toronto health
professionals. Psychiatry Journal of University of Ottowa, 12, 35–40.
Masters, W., & Johnson, V. (1970). Human sexual inadequacy. Boston: Little Brown.
McMahon, C. G. (1998). Treatment of premature ejaculation with sertraline HCL: A
single-blind placebo controlled crossover study. Journal of Urology, 159, 1935–
1938.
Moore, J. T., & Goldstein, Y. (1980). Sexual problems among family medicine pa-
tients. Journal of Family Practice, 10, 243–247.
Roblin, D. (2000). Premature ejaculation: Diagnosis and pharmacotherapy. Interna-
tional Journal of Pharmaceutical Medicine, 14, 313–318.
Rowland, D. L., & Slob, A. K. (1997). Premature ejaculation: Psychophysiological
considerations in theory, research and treatment. Annual Review of Sexual Re-
search, 8, 224–253.
Rust, J., Golombok, S., & Collier, J. (1988). Marital problems and sexual dysfunction:
How are they related? British Journal of Psychiatry, 152, 629–631.
Seftel, A. D., & Althof, S. E. (1997). Premature ejaculation. In J. J. Mulcahy (Ed.),
Diagnosis and management of male sexual dysfunction, pp. 196–203. New York:
Igaku-Shoin.
Semans, J. (1956). Premature ejaculation. Southern Medical Journal, 49, 352–358.
Seidman, S. N., Roose, S. P., Menza, M. A., Shabsigh, R., & Rosen, R. (2001). Treat-
ment of erectile dysfunction in men with depressive symptoms: Results of a
placebo-controlled trial with sildenafil citrate. American Journal of Psychiatry,
158, 1623–1630.
Shabsigh, R., Klein, L. T., Seidman, S., Kaplan, S. A., Lehrhoff, B. J., & Ritter, J. S.
(1998). Increased incidence of depressive symptoms in men with erectile dys-
function. Urology, 52, 848–852.
Spector, I. P., & Carey, M. P. (1990). Incidence and prevalence of sexual dysfunc-
tions: A critical review of the empirical literature. Archives of Sexual Behaviour,
19, 389–408.
St. Lawrence, J. S., & Madakasira, S. (1992). Evaluation and treatment of premature
ejaculation: A critical review. International Journal of Psychological Medicine,
22, 77–97.
Waldinger, M. D., Hengeveld, M. W., Zwinderman, A. H., & Olivier, B. (1998). An
empirical operational study of DSMIV diagnostic criteria for PE. International
Journal of Psychiatry in Clinical Practice, 2, 287–293.
World Health Organisation. (1992–1994). International statistical classification of
diseases and related health problems (10th ed.). Geneva, Switzerland: Author.